Strategic decision-making for redo cardiac surgical patients with biventricular heart failure – description of a surgical technique

Background: Left ventricular assist devices (LVADs) play a critical role in managing end-stage heart failure (HF), serving as a bridge to transplantation (BTT) or as destination therapy (DT). Patients with prior mechanical valve replacements who later require LVAD support present unique surgical challenges, including increased thrombotic risk, hemodynamic mismatch, and prolonged operative time. To address these concerns, direct balloonexpandable transcatheter heart valve (B/Ex-THV) implantation offers a minimally invasive alternative for high-risk redo cases. Objective: To evaluate the feasibility, safety, and hemodynamic performance of direct B/Ex-THV implantation combined with HeartMate 3 LVAD in high-risk patients with prior mechanical valve surgery or native aortic valve disease. Methods: This retrospective case series included 16 patients undergoing concomitant HeartMate 3 LVAD and direct B/Ex-THV implantation between April 2022 and October 2023. Nine patients received THVs anchored within prior mechanical prostheses (valve-in-frame), while seven underwent implantation into the native aortic annulus (valve-in-ring). Procedural metrics, hemodynamic outcomes, complications, and survival were analyzed. Results: All procedures were successfully completed. The valve-in-frame group demonstrated stable mid-term hemodynamics with low mean gradients (5.0 ± 1.3mmHg) and preserved effective orifice area. No significant paravalvular leak or structural deterioration was observed. At 30 days, 93.75% of patients survived; 12 and 24-month survival rates were both 75%. No valve migration, thrombosis, or hemolysis occurred. One patient who underwent valve-in-frame implantation subsequently underwent successful orthotopic heart transplantation 12 months later. Conclusion: Direct B/Ex-THV implantation with concurrent LVAD surgery is a feasible and safe strategy in complex redo patients. It minimizes ischemic time, preserves hemodynamic function, and aligns with ISHLT recommendations, offering a promising approach for managing advanced HF in patients with previous valve interventions.